# Resources - Type: NTSB finding section - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Management](https://openairdocs.org/ntsb-findings/0402) › Resources - NTSB code: 040220 - Cases: 20 - In the probable cause: 11 - Fatal cases: 7 - All cases: https://openairdocs.org/ntsb-findings/040220/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/040220/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/040220 ## Cases per year (in the probable cause / all) - 2008: 1 / 1 - 2010: 1 / 1 - 2011: 0 / 1 - 2012: 2 / 2 - 2013: 0 / 2 - 2014: 3 / 4 - 2015: 1 / 1 - 2016: 0 / 1 - 2017: 1 / 1 - 2018: 1 / 3 - 2019: 1 / 1 - 2023: 0 / 1 - 2024: 0 / 1 ## Findings - [Adequacy of documents/info](https://openairdocs.org/ntsb-findings/04022045): 6 cases, 3 in the probable cause - [Adequacy of equipment](https://openairdocs.org/ntsb-findings/04022025): 4 cases, 2 in the probable cause - [Availability of personnel](https://openairdocs.org/ntsb-findings/04022010): 3 cases, 1 in the probable cause - [Availability of equipment](https://openairdocs.org/ntsb-findings/04022020): 3 cases, 3 in the probable cause - [Availability of documents/info](https://openairdocs.org/ntsb-findings/04022040): 2 cases, 1 in the probable cause - [Resources, general](https://openairdocs.org/ntsb-findings/04022000): 1 cases, 0 in the probable cause - [Adequacy of facilities](https://openairdocs.org/ntsb-findings/04022035): 1 cases, 1 in the probable cause ## Defining events in these cases - [Turbulence encounter](https://openairdocs.org/ntsb-events/360): 3 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 2 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 2 cases - [Fuel contamination](https://openairdocs.org/ntsb-events/193): 2 cases - [Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150): 2 cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 1 cases - [Landing area overshoot](https://openairdocs.org/ntsb-events/380): 1 cases - [Uncontained engine failure](https://openairdocs.org/ntsb-events/343): 1 cases - [Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340): 1 cases - [Wildlife encounter (non-bird)](https://openairdocs.org/ntsb-events/310): 1 cases ## Aircraft models (registry) - [Boeing 767-323](https://openairdocs.org/model/boeing-767-323): 2 cases - [Boeing 737-7H4](https://openairdocs.org/model/boeing-737-7h4): 2 cases - [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3): 1 cases - [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2): 1 cases - [Gates Learjet 35A](https://openairdocs.org/model/gates-learjet-35a): 1 cases - [Gates Lear Jet 25B](https://openairdocs.org/model/gates-lear-jet-25b): 1 cases - [Gulfstream Aerospace GVI](https://openairdocs.org/model/gulfstream-aerospace-gvi): 1 cases - [Continental Copters TOMCAT MK5A](https://openairdocs.org/model/continental-copters-tomcat-mk5a): 1 cases - [Boeing 787-8](https://openairdocs.org/model/boeing-787-8): 1 cases - [Boeing 777-223](https://openairdocs.org/model/boeing-777-223): 1 cases ## Other findings in the same cases - [Training, general](https://openairdocs.org/ntsb-findings/04031000) (Organizational issues): 4 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 4 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 3 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 3 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 3 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 3 cases - [Oversight of reg compliance](https://openairdocs.org/ntsb-findings/04032040) (Organizational issues): 2 cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 2 cases - [Emergency proc training](https://openairdocs.org/ntsb-findings/04031030) (Organizational issues): 2 cases - [Safety](https://openairdocs.org/ntsb-findings/04024010) (Organizational issues): 2 cases ## Newest cases - [NTSB DCA24FA143](https://openairdocs.org/ntsb/DCA24FA143), Apr 3, 2024: Boeing 737-7CT (N567WN), Gulf of America (Gulf of Mexico), no damage. Probable cause: The pilot’s inadvertent encounter with convectively induced turbulence from a broken line of embedded thunderstorms moving across the region. Contributing to the accident was the failure of the air… - [NTSB DCA23LA465](https://openairdocs.org/ntsb/DCA23LA465), Sep 28, 2023: Boeing 787-8 (N804AN), Lake Erie Beach, NY, no damage. Probable cause: Malfunctioning brakes on a service cart. - [NTSB ANC20MA010](https://openairdocs.org/ntsb/ANC20MA010), Dec 27, 2019: Airbus AS350B2 (N985SA), Kekaha, HI, destroyed, 7 fatal. Probable cause: The pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological conditions (IMC), which resulted in the collision into terrain. Contributing to the accident was… - [NTSB DCA19IA036](https://openairdocs.org/ntsb/DCA19IA036), Dec 6, 2018: Boeing 737 (N752SW), Burbank, CA, incident, minor damage. Probable cause: (1) The flight crewmembers’ decision, due to plan continuation bias, to continue the approach despite indications of windshear and a higher-than-expected tailwind and (2) the flight crew’s… - [NTSB DCA18MA142](https://openairdocs.org/ntsb/DCA18MA142), Apr 17, 2018: Boeing 737 7H4 (N772SW), Philadelphia, PA, substantial damage, 1 fatal. Probable cause: A low-cycle fatigue crack in the dovetail of fan blade No. 13, which resulted in the fan blade separating in flight and impacting the engine fan case at a location that was critical to the structural… - [NTSB CEN18LA119](https://openairdocs.org/ntsb/CEN18LA119), Mar 10, 2018: Czech Sport Piper Sport (N422PS), Addison, TX, substantial damage. Probable cause: The operator’s use of improper fuel, which resulted in partial loss of engine power due to vapor lock. - [NTSB CEN18FA063](https://openairdocs.org/ntsb/CEN18FA063), Dec 31, 2017: Cessna 208 (TI-BEI), Punta Islita, Costa Rica, destroyed, 12 fatal. Probable cause: The flight crew's failure to maintain airspeed while maneuvering to exit an area of rising terrain, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic… - [NTSB DCA17FA021](https://openairdocs.org/ntsb/DCA17FA021), Oct 28, 2016: Boeing 767 (N345AN), Chicago, IL, substantial damage. Probable cause: The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the… - [NTSB GAA15CA163](https://openairdocs.org/ntsb/GAA15CA163), Jun 22, 2015: Gates Learjet 35A (N640BA), Grosse Ile, MI, substantial damage. Probable cause: The airplane's collision with a deer on the unfenced runway during the takeoff roll. Contributing to the accident is the airport's failure to establish a continuous fence between the runway and the… - [NTSB DCA15MA019](https://openairdocs.org/ntsb/DCA15MA019), Oct 31, 2014: Scaled Composites 339 (N339SS), Koehn Dry Lake, CA, destroyed, 1 fatal. Probable cause: Scaled Composites' failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SpaceShipTwo vehicle. This failure set the stage for… NTSB has coded findings and defining events since 2008; earlier cases used its older occurrence and cause codes and aren't counted. Findings: https://openairdocs.org/ntsb-findings.md. Defining events: https://openairdocs.org/ntsb-events.md. Phases of flight: https://openairdocs.org/ntsb-phases.md. Every investigation, filtered by finding, event, phase, state, year or model: https://openairdocs.org/ntsb.md (for example ?state=MI&fatal=1). NTSB's definitions: Accident and incident, 49 CFR 830.2 (https://www.ecfr.gov/current/title-49/subtitle-B/chapter-VIII/part-830/subpart-A/section-830.2), CICTT occurrence categories (PDF) (https://www.ntsb.gov/safety/data/Documents/datafiles/OccurrenceCategoryDefinitions.pdf), CICTT phases of flight (PDF) (https://www.ntsb.gov/safety/data/Documents/datafiles/PhaseofFlightDefinitions.pdf), and NTSB coding manual, before 2008 (PDF) (https://www.ntsb.gov/GILS/Documents/codman.pdf). NTSB publishes no definitions for its findings, only their names. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.